Baby's death 'completely avoidable'

A couple whose baby was delivered stillborn have spoken of their "horrendous ordeal" after a hospital admitted she would have lived if it was not for a series of blunders.

Deborah and Richard Horner were speaking about the death of their daughter Abbie after the NHS trust which runs St James's Hospital in Leeds admitted liability and agreed an undisclosed settlement with the family.

They said Abbie was delivered stillborn on August 17 2011 following an emergency caesarean section.

According to the family's lawyers, an investigation found that her death was caused by a catalogue of errors and poor communication by midwives which led to her brain being starved of oxygen.

The midwife in charge of Mrs Horner's care was referred to the Nursing and Midwifery Council and given a 12-month suspension order, the lawyers said.

She has now retired.

"To this day we are still shocked and appalled by what we went through and the tragic loss of our daughter Abbie," said Mrs Horner, 46, who lives in north Leeds.

"To know that our baby would have been born healthy had it not been for the failures to report her abnormal heartbeat is incredibly difficult to come to terms with.

"Everyone makes mistakes but there are lives at stake and my baby deserved the best possible care but, sadly, both she and I were failed."

Mrs Horner said: " My family have not even received an apology despite the trust's admission.

"This is just shocking and has left us very angry.

"It is just beyond belief how you could treat someone like that.

"We never want anyone else to have to suffer the same heartache we did and although we know the trust said improvements would be made immediately, we want to see proof of this.

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"Nothing will ever bring our daughter back but if they can apologise and prove that lessons have been learnt and shared across the NHS then hopefully we can start to put this horrendous ordeal behind us and try and re-build our lives."

Kelly Morris, a lawyer at Irwin Mitchell who represents the couple, said Abbie's death was completely avoidable.

She explained how Mrs Horner's pregnancy was considered high risk as she was 43-years-old and had previously suffered a miscarriage, yet no delivery or induction plan was agreed for her.

Ms Morris said an internal investigation into the midwife in charge's actions found breaches including the m isinterpretation of the CTG (foetal heart trace), i nadequate and inaccurate record keeping, f ailure to keep mother and baby the focus of care, f ailure to act within trust guidance.

Ms Morris said: " The loss of baby Abbie has truly devastated Deborah and Richard because she should still be alive today.

"Despite having the technology to identify when a baby's heartbeat is irregular or weak through the CTG machine, changes on the monitor were not reported correctly for a period of eight hours which prevented the appropriate action, such as an emergency caesarean, being taken sooner.

"This meant that Abbie suffered catastrophic brain damage.

"We welcome the fact the trust has admitted responsibility for the failings but it is concerning that Deborah and Richard have not had an apology for their loss.

"Abbie's death was completely avoidable and we hope that the action plan drawn up by the trust has been shared throughout the NHS to ensure the same mistakes are not repeated and patient safety is protected."

Julian Hartley, Chief Executive of Leeds Teaching Hospitals NHS Trust, said: " The events leading up to the loss of Abbie fell far short of the high standards of care we normally provide and for this I am very sorry.

"A full investigation led by a senior doctor was undertaken into the failure to recognise and escalate concerns in the labour care.

"This report has been shared with Mr and Mrs Horner and I can reassure them that we are committed to using this to ensure we learn from every aspect of what happened.

"Quite rightly our clinical staff have to be accountable for their actions."

Mr Hartley said the midwife concerned was immediately removed from practice and referred to the Local Supervisory Authority Midwifery Officer.

He said she subsequently chose to retire and is no longer employed by the trust.

He said: "In 2012, our head of midwifery and lead consultant met personally with Mr and Mrs Horner to discuss their concerns and to express their profound condolences and apologies.

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"I am very sad to hear that Mr and Mrs Horner feel they have not had an apology from the trust, as we have done our best to provide this.

"As chief executive I would like to reiterate how sorry I am on behalf of everyone concerned in this tragic case."

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